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Psychiatric Nursing Essentials Role of the Nurse in Mental Health Settings • Competent Care Provider -Comprehensive Assessment -Treatment provision -Health care promotion -Education and empowerment -Care coordination Therapeutic Agent of Change -Work practices grounded in knowledge of use of the Nursing Process and therapeutic principles of care -Care Advocacy • Holistic Integration of care -Body and Mind are one Therapeutic Goals • Promote health and recovery • Prevent relapse or exacerbation • Promote continued healthy growth and development • Educate and empower Elements of Therapy • • • • • Therapeutic Relationship Therapeutic Process Therapeutic Use of Self Therapeutic Communication Therapeutic Environment Therapeutic Relationships • Planned -Specific and goal oriented • Time Limited • Role Specific - Boundaries Based - Unequal relationship - Not a social relationship - Not quid pro quo • Client Centered Therapeutic Process • Episodic -Opening, working, closing • Engagement driven • Client centered • Treatment Specific Therapeutic Use of Self • Nurse acts as an agent of change -Helping others help themselves • Nurses practice effective self management -Self Awareness -Presentation -Self Care Therapeutic Communication • Mindful Use of Therapeutic communication Techniques -Word Choice/Content -Tone -Volume -Paralanguage Therapeutic Environment • Milieu Therapy • Culture of care -Formal Standards of care, Policies and Procedures Best practice protocols Administrative Practices -Informal Attitudes, perceptions, actual practices Psychiatric Nursing Process • • • • • • • Holistic Addresses physical and mental health needs Basis for delivery of comprehensive health care necessary for best outcomes for treatment of primary care issues and managing comorbidities -e.g. Depression and chronic pain Bipolar Disorder and Substance Abuse Care decisions and practices are plan driven and based on utilization of the Nursing Process, standards of care and evidence based practice utilizing sound therapeutic principles Process phases: -Assessment, Diagnosis (nursing), planning, Implementation, Evaluation Psychiatric nurses have to have a thorough grounding in human physiology, normal growth and development across the lifespan , pathophysiology, pharmacology basics, nursing and care delivery theory, PLUS Abnormal or pathopsychology, psychopharmacology, DSM nosology and preferably a grounding in wellness promotion and transcultural nursing Comprehensive Health Assessment • • • • Current functional Assessment Historical functional assessment Developmental history Family History -Psychiatric issues, diagnoses -Physical Health issues, diagnoses • Health assessment -Current status and historical comorbidity Comprehensive Assessment • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Date of Service: / / : Medical Record Number: Patient Name: Date of Birth: / / Provider: Sources of information: Patient M F GM GF Guardian Chart preview Reliability of Historian: Unreliable Poor Fair Good Reliable Identifying Data: Age, gender, relational status, occupation, ethnicity, primary language, religious affiliation Chief Complaint/Presenting problem: History of presenting illness (HPI): Onset: Why Now? : Triggers/Stressors (Scale 1-10): /10 Mood (Scale 1-10): /10 Depressive sx: ↓concentration/indecisiveness fatigue despair/hopelessness anhedonia ↓ Libido ↓ frustration tolerance Guilt amotivation irritability Aches/pains Mania: Expansive mood Reduced sleep drive Grandiosity Pressured speech hypersexuality Risk taking/Elevated goal directed behaviors Anxiety Symptoms: Panic Flooding/shut down Racing thoughts Rumination Avoidance Physical Sleep Patterns: Insomnia initial ____/min____/ Wk Interruptions ____min/____/ night____/Wk Av hours: Early wakening____/min____/Wk Daytime tired sleepy Naps ____min ___/WK Phobias: Dissociation: Fugue lost time derealization depersonalization Deepest Fears: Obsessions: Compulsive behaviors: Hoarding Picking Rituals Eating pattern: WNL Erratic Skipping meals no/low /increased appetite binging/purging craving Eating Disorder: Restriction binging/purging laxative use excessive exercise Trauma: Memories Nightmares Hypervigilance High startle Cognitive dulling Emotional distancing Psychosis: A/V/T/G/S Hallucinations (describe): Delusional content: Reference persecution insertion/broadcasting /control other (describe): Inattention hyperactivity impulsivity cant’ focus off task intrusive interruptive lack of follow through “on the go” Loosing things finishing others sentences avoiding mentally taxing/boring tasks Suicidal Ideation: Current: Passive Active: Intent Plan Access history Last time: Plan (describe): Means available? N/Y SA : N Y: Homicidal Ideation: Current Passive Active: Intent Plan Access history Last time: Plan (describe): Means available? N/Y Self- Harm Ideation: Current Passive Active: Intent Plan Access history Cutting/scratching/burning/abrading/pinching/carving/constricting/hitting/biting Last time: Plan (describe): Means available? N/Y Comprehensive Assessment • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Psychiatric History: Previous treatment? (Describe): N/Y Inpatient/OP (Describe, times/dates): Previous providers: Therapist/Psychiatrist/GP Past medications: Medications: Past Diagnoses: Family History: Substance abuse history: N/Y Treatment: N/Y : Drug Name Onset Frequency Amount Last use Complications Quitting ETOH THC Heroin/opiates Meth Cocaine Spice/ Ecstasy/Ketamine Hallucinogenics Inhalants Barbiturates Other’s medications Nicotine Caffeine Medical History: Primary Provider: Allergies: NKDA NKFA Seasonal Cat/Dog metal latex detergents/deodorant/ bee sting/spider bite Anaphylaxis Oral allergy syndrome adverse reaction Surgeries: Chronic health issues/Diagnoses: Last Exam; Medical: Dental: Vision: Ob/Gyn: Immunizations: Current S/T/W PPD Hep A/B Gardasil Influenza Shingles Pneumococcal Birth control: N/A Depo Implanon BCP IUD Nuva ring Mirena condom Essure Accidents: MVA: FX : LOC/Concussion : Current Review of Systems (ROS): Vitals: Hght Wght B/P P R T G W BMI General- Autoimmune Infections Hepatitis HIV Cancer Obesity Vitamin Deficiency Weight loss/gain Neuro- sz tic tremor ataxia parathesia akathesia loss of strength/motor/sensory vertigo/dizziness HEENT- HA migraines Colorblind Myopia/presbyopia/astigmatism Hearing loss tinnitus ear-tubes epistaxis broken nose deviated septum gastric reflux dysphagia missing/broken teeth bruxism TMJ CV-murmur MI palpitation TIA arrhythmia stroke Ischemia Raynaud’s Blood clots varicose veins CAD Pulm- SOB asthma emphysema COPD productive cough night-sweats malaise OSA RSV TB Inhaler GI- N/V/D/C/J IBS Crohn’s Disease Gluten / Lactose Intolerance Hemorrhoids Rectal Bleeding Cirrhosis of liver Gout Kidney stones Gall stones Endo/Hem- Hyperlipidemia HTN hypotension Diabetes I II Anemia hypoglycemia Thyroid Derm- Eczema psoriasis acne dermatitis scabies lice impetigo MRSA warts: M/S- myalgia arthritis : Chronic pain Carpal tunnel Degenerative disc scoliosis/kyphosis Osteoporosis G/U- menarche G: P: Msc Ab STD: N/Y: Sexually active: N/ Y First sexual experience Dysmenorrhea Amenorrhea Cysts Endometriosis Erectile dysfunction LMP: / / Comprehensive Assessment • • • • • • • • • • • • • • • • • • • • • • • • Developmental History: Gestational diabetes/HTN placenta previa nuchal cord meconium Birth: FT / Premature/late Vaginal C section Induced Apgar Jaundiced NICU Breast fed/Bottle fed Eating problems Croup/colic Fever Sleep problems Injury Crawl____@ month Walk____ @month Talk _____@month Potty trained ____@ month Abuse/Trauma Physical/emotional/sexual/neglect (describe): Behavioral Issues: Temper tantrums thumb sucking head banging biting self-rocking flapping arms Night terrors/ wandering /enuresis/ encopresis /cruelty to animals/ fire setting /Sexualized behaviors/masturbation/ nail biting /runaway/aggression/stealing/lying Property destruction/anorexia/binging/purging/smoking alcohol use/delinquency/truant/school failure Personality as a child: restless, overactive, hyperactive, withdrawn, timid, shy, passive, engaging, outgoing, intrusive, athletic Play style solo parallel bully victim best friend Y/N Pets N/Y: _________________________ General Statement about childhood: School History: 504 plan Tutor supplemental education IEP SED Speech Thx OT PT OCC THX Grades: Activities: Music Art Athletics Drama Pre K Elementary Middle High College Major Degree Grad Degree Social History: Date of Birth/place: Siblings/birth order: Occupational status: U/E Disabled SSI SSDI CAMA Work history: Religion or Spirituality: N/Y- _____________ attends services N/Y Social Support/Friends: N/YCurrent living situation: Homeless ARC Apt: ____BR House: _____BR Trailer: ______ BR yard Alone Spouse/S/O Children pet sibling blended family multi-generational Abuse History: Sexual physical emotional Neglect: Legal history: Misdemeanor Felony Incarceration: SIS Parole Probation Community Service DUI DMV V/P State custody Diminished capacity Mental Status Exam: Treatment Provision • • • • • • Medication Management -Ensuring informed consent Psychoeducation or consulting with provider -Administering medication “5 rights”: Right patient, right medication, right dose, right route, right time -Monitoring for compliance, side effects -Managing complications -Evaluating efficacy Mental Health Provision -Mental status and functional assessment -Individual Psychoeducation -Group psychoeducation Primary Health care provision Safety Assurance Documentation and reporting Outcome evaluation Psychiatric Medications The Art and Science • • • • Medication therapy is often a primary psychiatric nursing function Standards of practice for safe administration of medications are a core element Knowledge of medications is essential and takes often years to truly develop expertise in expected effects, potential side effects, pharmacokinetic and pharmacodynamics This should be imbedded in the context of care with assessment of the many elements besides the actual medications that can effect care outcomes such as -patient’s knowledge, cognitive state and understanding -patient (and often caregiver/families)beliefs and attitudes regarding medication therapy -barriers and promoters that will influence medication therapy outcomes Access to medication Environmental conditions Resources assessment; money food ect Psychiatric Medications • • • • • Antidepressants Anxiolytics (Antianxiety) Mood stabilizers Psychostimulants Antipsychotics Psychiatric Medications • Expected Effects versus Side effects -General caveat: older generation medications are more potent and have more side effects -We trade safety for efficacy on many occassions Antidepressants • Three “generations” • MAO inhibitors • Tricyclics • SSRI and later SNRI SNDI Anxiolytics • Antidepressants • Benzodiazapines • Non Benzodiazapines Mood Stabilizers • Anticonvulsants • Antipsychotics Antipsychotics